Citation Nr: 9822939
Decision Date: 07/29/98 Archive Date: 08/04/98
DOCKET NO. 94-17 188 ) DATE
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On appeal from the
Department of Veterans Affairs (VA) Regional Office (RO)
in Winston-Salem, North Carolina
THE ISSUES
1. Entitlement to service connection for an additional eye
disorder, including macular degeneration and retinal
degeneration of both eyes.
2. Entitlement to special monthly compensation benefits
based on the need for regular aid and attendance or at the
housebound rate.
REPRESENTATION
Appellant represented by: Disabled American Veterans
ATTORNEY FOR THE BOARD
M. E. Larkin, Associate Counsel
INTRODUCTION
The veteran served on active duty from October 1942 to
September 1945.
This matter was initially before the Board of Veterans’
Appeals (Board) on appeal from a January 1994 rating action
of the RO.
The Board remanded the case in June 1996 for further
development.
The Board again reviewed the case in December 1997 and
determined that it was necessary to obtain an opinion from a
medical expert within the Veterans Health Administration
(VHA). The requested opinion has been rendered and the
veteran’s representative has been provided with a copy of
that opinion and afforded an opportunity to respond thereto.
CONTENTIONS OF APPELLANT ON APPEAL
The veteran contends that he has service-connected
disabilities which are of such severity as to warrant the
assignment of special monthly compensation because he needs
assistance in the activities of daily living.
DECISION OF THE BOARD
The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991 & Supp. 1998), has reviewed and considered
all of the evidence and material of record in the veteran's
claims file. Based on its review of the relevant evidence in
this matter, and for the following reasons and bases, it is
the decision of the Board that the preponderance of evidence
is against the claim of service connection and against the
claim for special monthly compensation benefits based on the
need for regular aid and attendance or at the housebound
rate.
FINDINGS OF FACT
1. All relevant evidence necessary for an equitable
disposition of the veteran’s appeal has been obtained.
2. The veteran's additional eye disorders, including macular
degeneration, retinal degeneration, cataracts and glaucoma
are not shown to have been present in service or for many
years thereafter.
3. The veteran’s recently demonstrated eye disorders,
including macular degeneration, retinal degeneration,
cataracts and glaucoma, are not shown to have been due the
injury suffered in service or to have been caused or
aggravated by his service-connected left eye disability.
4. The veteran is service-connected for schizophrenia, rated
as 100 percent disabling; defective vision, left eye, rated
as 20 percent disabling; and impaired hearing, rated as 20
percent disabling.
5. The veteran’s service-connected disabilities are not
shown to have rendered him bedridden or incapable of
performing functions of daily living, including feeding,
dressing attending to his needs of nature or protecting
himself from the hazards and dangers of daily living.
6. The veteran’s service-connected disabilities are not
shown to have caused the veteran to be substantially confined
to his dwelling or its immediate premises.
CONCLUSIONS OF LAW
1. The veteran does not have additional eye disorders,
including macular degeneration, retinal degeneration,
cataracts and glaucoma due to disease or injury which was
incurred in or aggravated by service; nor is any proximately
due to or the result of service-connected disability.
38 U.S.C.A. §§ 1110, 5107, 7104 (West 1991 & Supp. 1998);
38 C.F.R. §§ 3.102, 3.303, 3.306, 3.310 (1997).
2. The criteria for special monthly compensation benefits
based on the need for regular aid and attendance of another
person are not met. 38 U.S.C.A. §§ 1114, 5107, 7104 (West
1991 & Supp. 1998); 38 C.F.R. §§ 3.350, 3.352(a) (1997).
3. The criteria for special monthly compensation benefits at
the housebound rate are not met. 38 U.S.C.A. §§ 1114, 5107,
7104 (West 1991 & Supp. 1998); 38 C.F.R. § 3.350 (1997).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
I. Background
It is maintained by and on behalf of the veteran that
entitlement to special monthly compensation based on the need
for regular aid and attendance is warranted inasmuch as the
veteran needs assistance in the activities of daily living.
It is asserted that the veteran is limited in his ability to
function as a result of service-connected disabilities,
including schizophrenia, rated as 100 percent disabling;
impaired vision, left eye, with myopic astigmatism and
amblyopia exanopsia, rated as 20 percent disabling; and
impaired hearing, rated as 20 percent disabling. In addition
to the service-connected disabilities, the veteran has been
noted to be suffering from the following nonservice-connected
disabilities: degenerative arthritis, lumbar spine;
hemorrhoids; macular degeneration, retinal degeneration and
visual field defect of both eyes, with loss of vision, light
perception only, bilateral; and residuals, alleged shell
fragment wound right foot.
By a June 1981 rating action, the RO determined that the
veteran was entitled to special monthly compensation based on
loss of use of the left eye, having light perception only.
It was noted at that time that the veteran's service-
connected left eye condition was deteriorating with “some
evidence of possible other disease processes at work in the
left eye.”
In an August 1984 rating decision, the RO considered a
medical opinion which related the veteran's loss of visual
acuity of the left eye to a nonservice-connected disease
process and determined that the veteran was no longer
entitled to special monthly compensation benefits.
The Board initially reviewed the veteran's appeal in June
1996 and assumed jurisdiction of the issue of service
connection for additional eye disorders, including macular
degeneration and retinal degeneration of both eyes.
The medical evidence associated with the claims file includes
an August 1991 statement for consideration for aid and
attendance signed by a private physician who reported that
the veteran could not see, but was able to handle larger
objects, could feed himself if food was placed before him and
was able to find the bathroom.
In a November 1993 medical statement, another private
physician reported that, because of complete blindness, the
veteran required the assistance of another person.
The veteran was afforded VA examinations in June 1994 which
yielded diagnoses of history of blindness, left eye and
schizophrenia, undifferentiated type. The veteran reported
to an examination for aid and attendance/housebound
accompanied by his son and daughter. It was reported that
the veteran was confined to a wheelchair due to severe
weakness and instability of his lower extremities. The
examiner noted that, due to his blindness, the veteran
required help in bathing, shaving and fastening clothes and
was confined to his home unless taken out by someone else.
The Board remanded the case in June 1996 in order to obtain
additional medical evidence on the degree of impaired visual
acuity due to the service-connected myopic astigmatism and
amblyopia exanopsia and the effect of the service-connected
schizophrenia on the veteran's ability to care for himself.
The veteran presented to a VA eye examination in October 1996
and related a history of blindness in the left eye following
trauma in service. Diagnoses included those of blindness,
hypermature cataracts and glaucoma, both eyes. The examiner
noted that examination of the retina was impossible secondary
to the hypermature cataracts. The examiner opined that the
veteran's glaucoma and cataracts were “possible” from the
trauma experienced in service.
The report of an October 1996 psychiatric examination noted
that the veteran, who was accompanied by his daughter, was
alert and cooperative, with no loose associations or flight
of ideas. There were no bizarre motor movements or tics
observed. The examiner noted no delusions, hallucinations,
ideas of reference or suspiciousness. The veteran was
reported to be oriented and his memory, both remote and
recent, appeared to be adequate.
The veteran reported to an October 1996 VA examination for
aid and attendance/housebound accompanied by an attendant.
It was noted that, because of his blindness, the veteran had
very poor balance, could not stand but a few seconds at a
time, and could not walk without holding onto something or
having someone guide him. The veteran reportedly had daily
dizzy spells and monthly “psychological” spells for which
he required attendance. He required help with self-care
because of his blindness. The veteran was noted to be able
to leave his home only with help.
In a November 1996 statement, a social worker reported that
the veteran was admitted to a medical facility in October
1996 and noted to be in unstable condition as he was not
being cared for properly. The veteran refused rest home
placement despite a doctors recommendation and, therefore,
required increased assistance in the home.
In December 1997, the Board requested a VA medical opinion
from a specialist within the Veterans Health Administration
(VHA). It was requested that a physician review the medical
evidence and provide an opinion as to the likelihood that the
veteran's currently demonstrated glaucoma and cataracts were
due to injury in service. The Board pointed out that VA
examinations of record included a medical opinion which found
no correlation between the veteran's service-connected left
eye disability and his currently demonstrated visual defect
and an opinion which held that it was “possible” that the
veteran's glaucoma was due to the trauma sustained in 1944.
In the request for an opinion, the Board related the
veteran’s history of hospitalization in December 1944 after
being knocked unconscious by a shell blast. It was noted that
he had suffered a superficial wound to the right shoulder,
but had profuse bleeding from the mouth and nose for several
days. While hospitalized, he had a persistent tic in the
right eye. He also had astigmatism and amblyopia of the left
eye which caused defective vision of 20/100, corrected.
After examination, the diagnosis was that of hysterical
reaction, bilateral astigmatism with myopia, and amblyopia
exanopsia of the left eye. Service connection had later been
established for defective vision in the left eye.
In a January 1998 opinion, a VA Chief of Ophthalmology
reported that he had reviewed the claims file and history of
the veteran. It was the expert’s opinion that the veteran
was blind from open angle glaucoma and not from a traumatic
cause. The trauma in 1944 “could not” have caused glaucoma
or cataracts, as neither was present for at least 30 years
following the trauma. “It [was] inconceivable to the expert
that either was caused by trauma.” The expert noted that
the veteran had developed age-related glaucoma, cataracts and
macular degeneration. Unfortunately, the glaucoma had
destroyed his sight so any treatment directed to the
cataracts or macular degeneration was considered useless. In
sum, there was “no likelihood that [the veteran's] cataracts
[were] due to the artillery blast explosion in December
1944.” In support of that opinion, the expert noted that
records revealed that the veteran had had open angle glaucoma
since 1980 and eye examinations showed no evidence of
traumatic damage to the globes or eyeballs. The veteran's
cataracts were considered to be of the common age-related
type. There was no evidence of traumatic dislocation of the
lens or capsular rupture as would be seen if the veteran had
traumatic cataracts.
II. Analysis
The Board finds that the veteran’s claims are “well
grounded” within the meaning of 38 U.S.C.A. § 5107(a) (West
1991 & Supp. 1997). The Board further finds that the matters
have been adequately developed for the purpose of appellate
review.
A. Service connection
In general, service connection may be established for a
disability resulting from an injury suffered or disease
contracted in the line of duty, or for aggravation of a pre-
existing injury or disease in the line of duty. 38 U.S.C.A.
§§ 1110, 1131 (West 1991 & Supp.1997). The regulations also
provide that service connection may be granted for a
disability diagnosed after discharge, when all the evidence,
including that pertinent to service, establishes that the
disability is due to disease or injury which was incurred in
or aggravated by service. 38 C.F.R. §§ 3.102, 3.303(d)
(1997).
It is contended that the veteran's glaucoma, cataracts and
macular degeneration are related to service. A VA examiner
has indicated that a connection between the trauma sustained
in service and the veteran's glaucoma and cataracts was
“possible.”
The Board requested an advisory medical opinion from VA on
the question of a possible relationship between the currently
demonstrated glaucoma and cataracts and the reported injury
due to artillery blast explosion to which the veteran was
exposed in December 1944. The response received from the
medical expert indicated that, based on his review of the
medical record, there was no likelihood of such a
relationship. It was considered “inconceivable” that the
trauma sustained in service could have caused the glaucoma or
cataracts. The veteran was noted to have developed age
related glaucoma, cataracts and macular degeneration.
As this medical opinion has considered the entire evidentiary
record and addressed the specifics of the medical evidence in
this case, the Board finds it to be controlling as to the
question of service connection for the veteran’s additional
eye disorder, including macular degeneration and retinal
degeneration.
As the opinion offered as part of the October 1996 VA
examination reported that there was a “possible”
relationship between the service and the currently
demonstrated eye disability, the Board finds that the medical
record in its entirety does not present a basis for
concluding that the claimed glaucoma, cataracts or macular
degeneration was caused by the reported injury in service or
otherwise caused or aggravated by the service-connected
disability.
Following receipt of the VHA opinion, no additional competent
evidence has been submitted regarding these questions of
medical diagnosis and causation. As the negative evidence is
found to outweigh that which is positive on the merits of the
presented issues, service connection is not warranted.
B. Special Monthly Compensation
Special monthly compensation provided by 38 U.S.C.A.
§ 1114(s) is payable where the veteran has a single service-
connected disability rated at 100 percent and has additional
service-connected disabilities independently ratable at 60
percent, separate and distinct from the 100 percent service-
connected disability, involving different anatomical segments
or bodily systems, or is permanently housebound by reason of
service-connected disability or disabilities. This
requirement for housebound is met when the veteran is
substantially confined as a direct result of service-
connected disabilities to his dwelling and the immediate
premises or, if institutionalized, to the ward or clinical
areas, and it is reasonably certain that the disability or
disabilities and resultant confinement will continue
throughout his or her lifetime. 38 C.F.R. § 3.350.
Special monthly compensation also is provided for a veteran
who is permanently bedridden or so helpless as to be in need
of regular aid and attendance. 38 U.S.C.A. § 1114(l);
38 C.F.R. § 3.350(b).
Determinations as to the need for aid and attendance must be
based on actual requirements of personal assistance from
others. In making such determinations, consideration is
given to such conditions as: inability of claimant to dress
or undress himself, or to keep himself ordinarily clean and
presentable; frequent need of adjustment of any special
prosthetic or orthopedic appliances which by reason of the
particular disability cannot be done without aid; inability
of claimant to feed himself through loss of coordination of
upper extremities or through extreme weakness; inability to
attend to the wants of nature; or incapacity, physical or
mental, which requires care or assistance on a regular basis
to protect the claimant from hazards or dangers incident to
his daily environment. "Bedridden" will be a proper basis
for the determination and is defined as that condition which,
through its essential character, actually requires that the
claimant remain in bed. It is not required that all of the
disabling conditions enumerated above be found to exist
before a favorable rating may be made. The particular
personal functions which the claimant is unable to perform
should be considered in connection with his condition as a
whole. It is only necessary that the evidence establish that
the claimant is so helpless as to need regular aid and
attendance, not that there be a constant need. 38 C.F.R. §
3.352(a).
In this case, the veteran falls short of the initial
schedular requirement necessary for the assignment of special
monthly compensation benefits at the housebound rate.
Although his service-connected schizophrenia is rated at 100
percent, the veteran does not have additional service-
connected disabilities independently ratable at 60 percent.
Furthermore, the Board finds that the veteran’s service-
connected disabilities alone do not render him housebound or
require that he receive regular aid and attendance from
another person. A review of the medical evidence
demonstrates that the primary cause of the veteran’s need for
the care and assistance of another person and his inability
to leave his home is his blindness. As discussed
hereinabove, the Board has determined that the veteran's
blindness is not related to a service-connected disability.
The medical evidence which pertains to the veteran's service-
connected psychiatric disability includes the report of the
October 1996 VA examination. At that time, the examiner
indicated that the veteran was alert and oriented, without
delusions, hallucinations or flight of ideas; insight and
judgment appeared to be adequate. The Board notes that
although the veteran requires assistance to do so, he is able
to leave his home as needed. There is no indication that the
service-connected defective hearing has impacted the
veteran's ability to care for himself.
The medical evidence as a whole does not establish that the
veteran is substantially confined to his dwelling and its
immediate premises due solely to the service-connected
disabilities. In addition, there was no indication that the
veteran was unable to dress himself, keep himself ordinarily
clean and presentable or feed himself or protect himself from
the hazards of life due to service-connected disabilities.
As such, the Board finds that special monthly compensation
benefits based on the need for regular aid and attendance or
at the housebound rate are not warranted.
ORDER
Service connection for an additional eye disorder, including
macular degeneration and retinal degeneration of both eyes is
denied.
Special monthly compensation benefits based on the need for
regular aid and attendance of another person or at the
housebound rate are denied.
STEPHEN L. WILKINS
Member, Board of Veterans' Appeals
NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West
1991 & Supp. 1997), a decision of the Board of Veterans'
Appeals granting less than the complete benefit, or benefits,
sought on appeal is appealable to the United States Court of
Veterans Appeals within 120 days from the date of mailing of
notice of the decision, provided that a Notice of
Disagreement concerning an issue which was before the Board
was filed with the agency of original jurisdiction on or
after November 18, 1988. Veterans' Judicial Review Act,
Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The
date which appears on the face of this decision constitutes
the date of mailing and the copy of this decision which you
have received is your notice of the action taken on your
appeal by the Board of Veterans' Appeals.
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